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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003117
Report Date: 09/18/2023
Date Signed: 09/18/2023 12:31:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230131143919
FACILITY NAME:APPLE RIDGE ASSISTED LIVINGFACILITY NUMBER:
347003117
ADMINISTRATOR:MICHELLE HARDYFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:82CENSUS: 64DATE:
09/18/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brittnay RaganTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff did not assist resident to shower while in care.
Resident was not provided a hoyer lift.
Resident developed unstageable pressure wound while in care.
Facility staff did not seek timely Medical attention.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 09/18/2023 at 9:30 AM to deliver complaint findings, LPA met with Brittnay Ragan, and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed facility documents. Resident 1 (R1) was discharged from a skilled nursing facility (SNF) and admitted into Apple Ridge Assisted Living Facility on January 05, 2023. R1's Health Certification form LIC 602 was completed by a SNF physician. However, after R1 was discharged from a SNF, R1 no longer had an assigned physician, and the facility accepted R1 without having a primary care physician.



Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20230131143919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117
VISIT DATE: 09/18/2023
NARRATIVE
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After R1 moved into the facility, care staff became aware they were not able to meet R1's care needs. One need the facility was not able to meet was showering. R1 was not able to complete a safe transfer from their wheelchair to a shower chair. As a result, the facility did not allow R1 to shower at the common shower room. It was further learned that the facility did not conduct a reassessment to assess R1’s functional capabilities for showering.

R1 was offered three bed baths. A partial bed bath was provided on January 12, 2023, which consisted of washing hair and upper body limbs only. A second bed bath was given on January 16, 2023. A third bed bath on January 23, 2023, which it was noted R1 had a rash and redness on buttocks. During this initial change to bed baths, R1 voiced that they did not want bed baths and wanted to be showered. However, the facility did not implement a plan that would allow R1 to use the common shower in a safe manner, as R1 was offered showers during the initial pre-placement assessment and needs and service initial assessment.

The facility did not request or obtain a physician’s durable medical equipment (DME) referral for a shower chair because the facility accepted R1 without an assigned physician. The facility failed to implement a plan to address the need of a shower chair. Moreover, the facility did not implement a plan to address the need of a physician. A third need the facility was not able to meet was obtaining a hoyer lift for R1. The facility is a no dead lift facility, which the facility will not lift a resident off the ground, nor assist residents who are not able to assist with transfers. Due to the no dead weight lift facility policy, R1 required a hoyer lift for shower transfers. However, the facility did not implement a plan to address the need of a hoyer lift and did not address the need of obtaining a hoyer lift referral from a physician.

The investigation revealed the facility failed to meet R1's needs after accepting them into their facility. Additionally, the facility failed to obtain DME referrals and a physician for R1. Furthermore, the facility did not conduct a reassessment after they became aware that they were not able to meet R1’s needs. In addition, the facility did not address R1's request of wanting to be showered at the common shower room. As stated in Title 22 Regulations 87464 Basic Services, "… If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457... pre-admission appraisal and providing the other basic services specified below, either directly or through outside resources."

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20230131143919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117
VISIT DATE: 09/18/2023
NARRATIVE
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As R1's pre-assessment plan dated January 04, 2023, states, " Help with bathing, hair care, personal hygiene...one person assist." R1's facility periodic summary dated January 04, 2023, states, " encourage self-participation for bathing. Use shower chair and use the large shower room. Inspect skin during each shower and assist with bathing as needed.” As a result, the facility neglected to meet R1’s needs, and did not implement outside resources to meet R1’s needs. An immediate $500.00 civil penalty shall be assessed on September 18, 2023; based on the fact the facility failed to provide basic care services to R1 which posed an immediate threat to the Health, Safety, and Personal Rights of R1.

The investigation further revealed that R1 was admitted into Apple Ridge Assisted living after receiving SNF treatment for a stage four pressure injury to their Coccyx area. It was also learned the facility did not follow SNF’s discharge summary directives. The SNF discharge summary states the following, “Instruct pt/cg on pressure ulcer prevention: regular skin assessments, keep skin clean and dry, incontinence management, reposition every 2 hours.” The facility did not conduct a skin assessment prior to R1 moving into the facility. The facility also, did not conduct proper skin check assessments after R1 moved into the facility and did not seek timely medical attention. A January 23, 2023, facility note stated R1 had a rash and redness on buttocks. However, R1 was never sent out to the Emergency Room (ER), and the facility did not communicate with a physician due to R1 not having an assigned physician.

Furthermore, two out of six staff reported having knowledge of R1 having a pressure injury although R1 was never sent out to the ER. On January 29, 2023, R1 was sent out to the ER due to having behaviors. While R1 was at the ER, R1 was diagnosed with a stage four pressure injury that was five centimeters deep and infiltrated with stool. It was learned R1 was admitted into the hospital on January 30, 2023, due to their stage four pressure injury.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20230131143919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/19/2023
Section Cited
CCR
87464(d)
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87464(d) Basic services facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal ...This requirement was not met as
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Facility staff has implemented the following: Reviewing new resident assessments with all staff. Implemented new procedures on conducting assessments. Facility staff agrees Conduct All staff in-service
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evidence by: Based on record review & interviews the Licensee did not ensure staff were providing basic services to R1 and did not ensure staff were reassessing R1 after becoming aware they were not able to meet their care and shower needs. This posed an immediate health and safety risk to R1.
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training on assessments by POC date October 2, 2023. Facility staff agrees to email training agenda to LPA Martinez by POC date 09/19/2023 5 PM.
Deficiency Dismissed
Type A
09/19/2023
Section Cited
CCR
87464(f)(1)
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87464(f)(2) Basic Services: Basic services shall at a minimum include: Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement was not met as evidence by:
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Facility staff has implemented the following: Assessing resident on DME need, and ensuring new residents move in with all required DME.
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Based on file review and interviews the Licensee did not ensure staff assisted R1 in obtaining a hoyer lift and did not provide healthful living accommodations that would allow R1 to shower in common shower room. This posed an immediate health and safety risk to R1.
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Facility staff agrees to conduct an all staff in-service training on Basic Services/DME by POC date October 2, 2023. Facility staff agrees to email training agenda to LPA Martinez by POC date 09/19/2023 5 PM.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20230131143919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117
VISIT DATE: 09/18/2023
NARRATIVE
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According to the facility Administrator, they were unaware that R1 had a pressure injury therefore, they did not seek medical attention for R1. The Administrator also reported facility care staff should have caught the pressure injury and was an oversight and takes full responsibility for the incident. Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

Due to the findings of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.



An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 27-AS-20230131143919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: APPLE RIDGE ASSISTED LIVING
FACILITY NUMBER: 347003117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/19/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental and Medical The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Facility staff agrees to conduct an All staff in-service training on Seeking timely medical attention by POC date October 2, 2023. Facility staff agrees to email training agenda and training documents to LPA Martinez by POC date 09/19/2023
5 PM.
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This requirement was not met as evidence by: based on file review and interviews: The Licensee did not ensure R1 was sent out to hospital after facility staff became aware that R1 had skin break/pressure injury. This posed an immediate health and safety risk to R1.
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Deficiency Dismissed
Type A
09/19/2023
Section Cited
CCR
87464(f)(1)
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Basic Services 87464(f)(1):Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on file review and interviews, The Licensee did not ensure
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Facility staff reported skin breakdown pressure injury training was conducted on 09/07/2023. Facility staff agrees to email agenda and training documents to LPA Martinez by 09/19/2023 5 PM
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Staff were conducting skin breakdown checks as required and providing skin Integrity care and sending R1 to the hospital when R1 had signs of skin breakdown. This posed an immediate health and safety risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6